A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Limited hip abduction

Equal leg length

Symmetric gluteal and thigh skin folds

Femoral head remains in the acetabulum during the Barlow maneuver

Answer and Explanation

The Correct Answer is A

Rationale:

A. Limited hip abduction: Limited abduction of the hips in a 1-month-old can indicate developmental dysplasia of the hip (DDH). This finding warrants further evaluation, such as ultrasound imaging, to rule out structural abnormalities and initiate early treatment if needed.

B. Equal leg length: Equal leg length is a normal finding and does not require intervention. Leg length discrepancies are more concerning and often associated with hip dislocation or other musculoskeletal conditions.

C. Symmetric gluteal and thigh skin folds: Symmetry in the gluteal and thigh folds is a reassuring sign that typically rules out DDH. Asymmetry would be more suggestive of a hip abnormality requiring follow-up.

D. Femoral head remains in the acetabulum during the Barlow maneuver: This is a normal finding. The Barlow test assesses for hip instability, and if the femoral head remains stable within the socket, no further evaluation is needed.

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Correct Answer is ["A","B","C"]

Explanation

Rationale:

A. Assess the client's lung sounds prior to the infusion: Pre-transfusion assessment of lung sounds is essential to detect any baseline abnormalities and to monitor for fluid overload or transfusion-related lung complications such as transfusion-associated circulatory overload.

B. Infuse the blood over 4 hr: Older adults are at increased risk for fluid overload, so transfusing packed RBCs slowly over 4 hours is appropriate and safer, as long as the blood is completely administered within the maximum 4-hour window from removal from refrigeration.

C. Verify with another nurse that the unit of blood is compatible with the client's blood type: A dual verification process is mandatory to ensure safe administration. The nurse must check the client’s ID, blood type, unit number, and expiration date with another licensed professional before initiating the transfusion.

D. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime and flush blood transfusion tubing. Hypotonic solutions like 0.45% sodium chloride can cause hemolysis and should never be used with blood products.

E. Don sterile gloves to prepare the blood administration setup: Sterile gloves are not necessary for setting up a blood transfusion. Clean gloves are sufficient for handling equipment and initiating IV therapy, following standard precautions.

A. Place a warm pack on the incisional area. B. Restrict fluids to 1,200 mL per day. C. Elevate the client's scrotum on a pillow. D. Encourage the client to sit to void.

Correct Answer is C

Explanation

Rationale:

A. Place a warm pack on the incisional area: Applying a warm pack immediately postoperatively can increase blood flow and risk bleeding or swelling at the surgical site. Cold packs are generally preferred in the immediate postoperative period to reduce inflammation.

B. Restrict fluids to 1,200 mL per day: Fluid restriction is not indicated after hernia repair unless the client has a comorbid condition like heart or renal failure. Adequate hydration supports healing and normal bowel and urinary function.

C. Elevate the client's scrotum on a pillow: Elevating the scrotum helps reduce swelling and discomfort after hernia repair, especially if the inguinal area is involved. This intervention promotes venous return and prevents complications like hematoma formation.

D. Encourage the client to sit to void: Sitting to void is not routinely necessary after hernia repair unless the client has mobility issues. There’s no specific benefit to this position in a typical male postoperative client.

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A nurse is assessing a 1-month-old infant at a pediatric office. Which of the following findings requires a referral for further care?

Nursing Test Bank

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